Provider Demographics
NPI:1457477259
Name:DOELLMAN, BONITA MARIE (MA OTRL)
Entity Type:Individual
Prefix:MRS
First Name:BONITA
Middle Name:MARIE
Last Name:DOELLMAN
Suffix:
Gender:F
Credentials:MA OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-1353
Mailing Address - Country:US
Mailing Address - Phone:217-224-3259
Mailing Address - Fax:217-224-3259
Practice Address - Street 1:911 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-1353
Practice Address - Country:US
Practice Address - Phone:217-224-3259
Practice Address - Fax:217-224-3259
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005107225X00000X
IA01523225X00000X
IL225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist